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Motivational interviewing is patient centered, directive counseling aimed at helping patients to explore and resolve their ambivalence about behavior change. Motivational interviewing entails a combination of style (empathy and warmth) and technique (listening, focused reflective and development of a discrepancy). It also involves the patient’s motivation to change through a process of negotiation while articulating the costs and benefits involved. Miller and Rollnick, hence defining it as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”, later revised this definition (Miller & Rollnick 2002, p. 25).
In 2008, they further redefined it as “a collaborative person-centered form of guiding to elicit and strengthen motivation for change” (Miller & Rollnick 2009, p. 137). Motivational interviewing concept originated from a series of discussions between William Miller and Norwegian psychologist in 1982. Miller explained how he dealt with patients with alcohol problems, “As I explained and demonstrated how I counseled alcoholics, they asked wonderful probing questions about why I said what I did, what I was thinking, and why I pursued one line and not another,” (Miller 1995, p. 3). From there he wrote a manuscript on how to deal with the situation.
According to Miller and Rollnick, expression of empathy is a defining feature and fundamental of motivational interviewing by a counselor. In this concept, behavior change is possible if the client feels that he is being valued and personally accepted. The counselor empathy is viewed to be crucial in giving conditions required to explore behavior change successfully (Miller & Rollnick 2002). Developing discrepancy is another core concept, which involves exploring the cons and pros of the client present behaviors and changes to present behaviors in supportive and accepted environment. This develops awareness of the client discrepancy, values, and their broader objectives. Developing client’s discrepancies elicit progress towards consistency of client core values and behaviors (Miller & Rollnick, 2002).
The other concept is rolling with resistance or avoiding arguing with the client on their needs to change. In motivational interviewing, it is viewed that direct confrontations with the client about their change provokes reactance and continued resistance, hence reducing chances of change. Clients may fully dispute the need for change, but the target in motivational interviewing is not to subdue clients and offer them passive recipients of a counselor’s suggestions through the power of argument.
Rogers’ client-centered counseling is the basis for an empathic counseling style applied in motivational interviewing. This counseling style is also known as person –centered therapy as described by Carl Rogers in 1957(Rogers 1959). The famous psychologist also developed the principles of listening and explained its significant role in the creation of confidence. He further placed emphasis on the importance of the therapist rather than the method of treatment (Raistrick 2007). Another counseling technique is through the application of cognitive dissonance theory. This theory is the source of the principle of developing discrepancy as applied in motivational interviewing (Festinger 1957). Cognitive dissonance can be applied to different situations including attitude change and formation hence relevant to problem solving and decision-making. (Aronson, Fried, & Stone 1991; Cooper 2007). Self-determination theory is another counseling technique available for personality development and self-motivation (Markland, Ryan, Tobin & Rollnick 2005; Vansteenkiste & Sheldon 2006). This theory has led to the improved general understanding of how motivational interviewing works.
Motivational interviewing acclaims big support; it is a form of cognitive therapy that does not require assessment feedback. Raistrick (2007) explains that motivational interviewing is not just client-centered counseling, but it also entails eliciting from people what they already know. The theory is also founded on tenets that are goal oriented and with the intentional direction towards the desired goal.
Draycott and Dabbs (1998) argue that motivational interviewing lacks a theoretical base and this argument have been acknowledged by Miller and Rollnick (2002). It lacks a coherent theoretical framework, though there are many influences that led to the development of motivational interviewing. Many see motivational interviewing as complex method, which involves tricks to get people do what they do not want to do.
2. Scholars who Have Contributed to MI
Although Motivational Interviewing was first illustrated in 1983, it was not until 1995, when Rollnick and Miller gave the first clear definition of the same. The two described MI as a client-centered, directed counseling style that is aimed at obtaining behavior change by assisting clients to discover and resolve ambivalence (Miller & Rollnick 2002). They revised the definition slightly in 2002, describing it as a directive, client-centered technique for enhancing inherent motivation to change by discovering and resolving ambivalence. They further revised the definition in 2008, first announced by Miller ahead of an article in press in December 2008. They put it as a joint person-centered form of guiding to draw behavior and reinforce motivation for change.
Foucault is concerned with the various approaches by which human beings are made subjects, which assume the objectification of the subject by methods of division and classification. Foucault as a postmodernist tried to come up with a new theory of society through the study of how individuals becomes who and what they are. The major concepts of his discovery of the problem of the subject are those of knowledge and power, or more precisely, that of knowledge-power that he believed to be a single, inseparable design of practices and ideas that comprises of a discourse. Discourses are comprised of inclusions as well as exclusions of what can and cannot be said. These inclusions and exclusions stand in opposed relationship to other rights, claims, positions, possible meanings, and discourses (Miller & Rollnick 2002).
Foucault's focus is on questions of how the dialogues have created and shaped meaning systems, which have achieved the currency and status of truth, and dictate how we classify and categorize both ourselves and our social world. Other discourses are subjugated and marginalized, yet possibly provide sites where hegemonic practices can be resisted, contested, and challenged. In his view, there is no definitive and fixed structuring of either social practices or communally determined view, whereby the subject is totally socialized. Realizing how these discursive constructions are created may enable the way for contestation and alterations.
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According to Ledwiths theory, in a process of reflection and action, community development advances through a diversity of local projects that tackle problems faced by people in the community. Through motivational interviewing, a global reach is attained that changes the structure of subjugation affecting the lives of the locals (Ledwiths 2007).
The first principle is to develop discrepancy. It is to employ approaches that make it easy for the client’s identification of discrepant components of a specific behavior. It leads to client experiencing hesitant feelings. Areas of discrepancy include behavior versus objectives; past versus the present (Festinger 1957). Secondly, resistance is avoiding argumentation, which refers to the provider’s capacity to diminish resistance and move to link to the client in the same direction. Thus, this technique helps avoiding arguments. It assists in expressing empathy and shifting focus while supporting self-efficacy is the provider’s strength to support the client’s hopefulness that change is possible. It enhances the client’s confidence and hope.
3. Sense of Identity. Social Construction of Identity. Quotes and Scholars
The sense of identity appears early in life as infants begin to separate themselves from an undifferentiated unity with their mothers. This happens when the child realizes that he or she is a separate being of the same image. According to Miller (2009), a child may cling to a teddy bear hence understanding that they are different from a teddy bear. This transition objects cause distress to a child when it is removed because it is part of a child’s identity. This pattern continues in our lives until we identify to things that we have around us; hence, this is how a sense of identity is formed.
The social construction of identity is the formation of group identities that are not resistant to change hence not fixed. These are identities that are fluid and change according to individuals’ subjective evaluation and group circumstances in a given place and time. Emile Sahliyeh observed social construction of identity in terms that it “serves the practical needs and the interests of the members of the community. “ The durability of identity is contingent upon its ability to provide security, social status, and economic benefits for its members more than do other existing alternatives” (Emile 1993, p. 178). He further stated that, under favorable situation, alternatives for economic and social advancement present outside will make a person take advantage of the alternatives and modify his or her identity temporarily to suit the best desired social settings. The assumption of identity is that it is open to modification, malleable and can be reformulated or replaced “within the context of opportunity, constraint, and power” (Bette 1993, p. 44). The social construction of identity entails the formation of identities through compromise and political struggle, and performance hence contingent to the ability to provide social status, security and other economic benefits. This leads to individuals taking advantage of alternatives by changing their identities and implementing modifications to suit the benefits.
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4.Literature Review on Alcoholism. Benefits of MI for Alcoholic Patients
Alcoholism has been part of human history since ancient times. There are not only various ancient myths and biblical examples which refer to alcohol but also archeological findings and history proposes that consumption has been part of the African tradition, rituals, and culture since time immemorial. However, the fact of continuing alcoholism consumption and the inheritance through generations does not sufficiently explain why alcohol is consumed. Moreover, patterns of use of alcohol have changed considerably over time, and evidence indicates that the quantity consumed at present is greater than it was in the ancient times. The World Health Organization approximates that almost 2 billion people in the world take alcohol, and there is clearly no definite reason why they consume alcohol drinks. It is obvious though that drinking is caused by factors, such as social environment, gender, age, accessibility, genetics, personality and exposure. Most of the drug dependents abuse alcohol before becoming addicted to other drugs, such as cocaine.
Several studies have indicated that the application of Motivational Interviewing is useful in alcohol and drug dependency treatment. Brief MI has previously been developed for prevention objectives and secondary prevention as it targets youths in the initial stages of drug misuse. Brief MI in secondary prevention targets at lowering the drug consumption in drug use and making informed choice decisions possible.
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5. Current Literature on Person Centred Care for Alcoholics and Benefits of Using MI for Alcoholic Patients
Many health care systems worldwide are stressing the needs for more patient-centered care. Patient-centered care is a multi-facet idea that addresses the requirement for patient information, upholds concordance, boosts the professional-patient relationship, analyses the patient as a complex person. Health care professionals, however, vary in their capacity in terms of attaining an understanding of the patient standpoint and providing patient-centered care. One potential justification is that individual variations in the personal features of professionals may account for some of these differences. Assessment of the individual features of health experts and the way, how they might recount to patient-centered care, is an under-discovered and relatively new approach. There is no ultimate answer as to how crucial any such aspect might be as there are many psychological methods that might be considered, including an assessment of personality characteristics, as well as the concept of multiple intelligence that deals with areas beyond standard IQ, and the study of beliefs and attitudes.
6. Five Stages of Change.
The Stages of Change model states that the patient’s progress develops through five stages while undergoing behavioral changes. These stages are pre-contemplation which entail the patients having no intention to change behavior in any conditions whatsoever. Contemplation is another stage exhibited by consideration of making a change in the near future. After contemplation, there is the preparation stage, which features preparation to make a change. This is followed by the action stage whereby the client is actively involved in making the change happen in a reality. Finally, there is the maintenance stage, which involves maintaining the changes made. The stages of change model gives considerate guidance and procedures that are necessary to accomplish behavioral and motivational change (Raistrick 2007).
7. Chances of Alcoholic Patient Relapcing with MI Theory
Many clinicians have identified that skill in MI approach boosts the delivery of brief intervention. The aim is assisting youths and those affected to arrive at the conclusion that they require a change of behavior. These behaviors may be stopping smoking, changing dietary habits, lowering their alcohol use hence reducing the risk of STDs. Relapses are a frequent part of the recovery process, particularly after the first rehabilitation period has ended. It is crucial to avoid relapse if an individual has become addicted to drugs, due to the criminal consequences associated with these drugs. Motivational Interviewing approaches try to boost motivation for a patient to enter an addiction recovery program. Motivational inducements promote abstinence from drugs while using positive reinforcement. The patient’s motivation is a strong aspect in measuring the success of alcohol treatment program, regardless of the exact methodology of the program.
According to the theory of Psychological Reactance, the MI principle of avoidance of arguing for change (rolling in line with resistance) is influenced by psychological reactance as put forward by Brehm, in 1966 (Raistrick 2007). The theory suggests that a threat or loss of freedom forces a person to struggle in order to maintain that freedom. When individuals perceive an unjust restriction on their actions, a condition of reactance is activated. An individual with reactance is single-minded, emotional, and somehow irrational since reactance is an extreme motivational state.
8. Role of Autonomy, Empathy. Risks Relating to the Feeling of a Failure. Collaboration and Evocation in MI
It is through autonomy that the clinician recognizes that the power of change is within the client. This leads to empowering the clients to allow the changes happen while giving them responsibility to manage the change. It is believed that there is no single way to change, but it involves multiple techniques and procedures hence the need of avoiding being an authoritative figure. The essence of autonomy is to allow clients to lead in the creation of “change menu” in order to achieve the desired goal.Theory of Psychological Reactance supports autonomy in that there is a need to roll with resistance (Raistrick 2007). It argues that lack of freedom leads to the maintenance of that freedom hence a need to allow freedom and give the option to the clients.
According to Miller and Rollnick (1995), empathy is “a specifiable and learnable skill for understanding another's meaning through the use of reflective listening. It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning". Empathy is important in motivational interviewing to establish a safe environment, conducive in eliciting personal reasoning and examining the issues. It provides assistance all through the recovery process, allows one to support and acknowledge the consultant. Empathy communicates acceptance and feelings for the client, encourages nonjudgmental and collaborative relationship through listening technique, and finally, it compliments rather than denigrates the successful recovery.
Making a client feel like a failure leads to the belief that they cannot begin or maintain any behavioral change, and this cannot elicit any optimism, hope and feasibility of accomplishing change. The essence of motivational interviewing is to recognize the client’s strengths while bringing and nurturing them. Making the client feel like a failure will make the client feel that change is impossible, and this leads to a feeling of hopelessness hence resulting in denial and increase of discomfort. Self- belief is an essential component of behavior change. Believing in the clients’ abilities is paramount in enabling them to reach their goals. Instead of taking a client as a failure, the clinician should encourage and talk about other successful people who were in similar conditions.
To roll with resistance during motivational interviewing is important in identifying if there is poor treatment and non-participation in the therapeutic process to avoid client behaving defiantly. Resistance makes the client view situations differently; hence, clinician should understand client perspective and make a follow up. Resistance signals change direction or to be conscious on the change behaviors. Motivational interviewing is important to roll the resistance to avoid chances of responding in different ways due to advantageous situation without confrontations. According to Raistrick (2007), rolling resistance is one way of avoiding adjustments offering chances, which express empathy through being respectful and nonjudgmental. The client should not remain alone after interviewing to avoid resistance.
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Evocation draws out the person’s own skills of change and motivations. Therapists should not impose their opinions and ideas - commitment and motivation are powerful when it comes from the client. Evocation enables the client to discover their own reasons and determination to change, hence promoting lasting change (Armitage & Conner 2000).
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